Last year, my family became seriously ill. After some initial testing, a malignant tumor was diagnosed. Surgery was scheduled, followed by chemotherapy. Everything went almost as planned and there were no medical problems. We are both well educated and have a background in medicine, health economics and risk analysis, so we meet the requirements of health insurance providers and handle out-of-pocket and pre-approval as needed. You need to be prepared to be.
We were terribly wrong.
You have chosen to place your provider, surgeon, and facility all within your network. The problem is that some of these facilities use radiologists, pathologists, and anesthesiologists who choose to stay off the network.
Why is this done? These specialists receive higher payments when they are off the network than when they are on the network. Refund rates are low within the network. This means that the patient will be responsible for the charges for such services, even in the absence of such a provider’s choice.
In Illinois, legislation protects patients from such situations. Insurance contracts require what is called facility-based provider benefits. That is, if a patient is treated at a hospital within the network and is provided by a radiologist, pathologist, or anesthesiologist outside the network, these services are considered in-network. , And in most cases, you will be charged at the rate specified by your provider.
Despite the benefits of facility-based providers, insurers may add rules and restrictions to coverage that prevents communication. For example, you may need to claim pathology on the same day as the procedure in your network. Therefore, if a pathologist charges for work the day after care is provided at a facility within the network, the insurance company may reject the claim and effectively move to the pathologist’s direct claim. I have.
Another example occurs when a pathologist needs to use the specified number of units for histological analysis, but the insurance company has an arbitrary limit on the number of units that can be claimed per day. If this limit is exceeded, the insurance company will reject all claims instead of paying up to any limit.
Another problem with these unwritten rules is that the patient is responsible for understanding them and communicating them to the doctor’s billing office. Otherwise, the billing office will consider the claim rejected without specifying a reason and will bill the patient directly.
The No Surprise Act, which came into force in 2022, provides comprehensive protection against such billing practices nationwide and provides patients with financial protection beyond the interests of facility-based providers.
The lesson I learned from my family’s illness is that there is a triumvirate of players that is out of sync with each other.
First, there are healthcare providers in the network who want to provide care and pay for services. Second, there are insurers that have a vested interest in providing minimal payments for services and maintaining a veil of uncertainty about rules and policies.
Finally, there are patients who work to stay in the network, but are responsible for the legitimate fees covered by health insurance, but require sophistication and communication to facilitate payment.
What I can say about health insurance is that it’s great when you don’t have to use it. However, when large-scale medical events require large-scale and complex care and services, patients become innocent bystanders and get stuck between the medical care provided and the insurance companies that have to pay for it.
A system that creates a seamless network of providers covered by all insurance companies. Without such a simple set of transparent rules for insurers and providers, patients would continue to go through the cracks with uncovered medical costs falling to them.
Changes are needed whether this means a single payer system or multiple payers who adhere to a unified set of rules.
The current system is unsustainable. COVID-19 further revealed the problem. Health providers are overwhelmed by more patients than they have resources to treat.
The illness of my family has opened our eyes to the medical condition of our country. Both patients and doctors are respected and deserve fair treatment by the health insurance industry, so patients receive the medical care they need and doctors can continue to be in charge of the medical care they provide.
Sheldon H. Jacobson He is a professor of computer science at the University of Illinois at Urbana-Champaign.
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